Renal medicine in the intensive care unit: a narrative review

Abstract

Summary Kidney disease, both acute and chronic, is commonly encountered on the intensive care unit. Due to the role the kidneys play in whole body homeostasis, it follows that their dysfunction has wide‐ranging implications and can affect prescribing and therapeutic management. This narrative review discusses the pathophysiology of acute kidney injury and chronic kidney disease, and how this relates to critically unwell patients. We cover several aspects of the management of renal dysfunction on the critical care unit, exploring some of the recurrent themes within the literature, including type and timing of kidney replacement therapy, management of acute kidney injury, as well as discussing how novel biomarkers for acute kidney injury may help to identify patients suffering from acute kidney injury as well as risk stratifying these patients. We discuss how early involvement of specialist nephrology services can improve outcomes in patients with kidney disease as well as offer valuable diagnostic and specialist management advice, particularly for patients with established end stage kidney disease and patients who are already known to nephrology services. We also explore some of the ongoing research questions that need to be answered within this arena.

Acute Kidney Injury in Kidney Transplant Patients in Intensive Care Unit: From Pathogenesis to Clinical Management

“…However, in the context of the transplant setting, chronic immunosuppressive treatment plays a role in impairing the immune response as compared to the general population. Regardless of the etiology of AKI in kidney transplant recipients, there are several pathophysiological mechanisms involved in the disease's development and course, including hemodynamic and microcirculatory alterations, endothelial dysfunction and tubular cell damage [77]. These processes are characterized, in the first instance, by changes in renal blood flow that may cause reduced graft perfusion and consequent renal ischemia; secondly, ischemic damage may result in a reduced cellular supply of oxygen and metabolic substrates with subsequent cellular damage, production of ROS and activation of inflammation, coagulation and complement pathways [77,78].…”

“…Regardless of the etiology of AKI in kidney transplant recipients, there are several pathophysiological mechanisms involved in the disease's development and course, including hemodynamic and microcirculatory alterations, endothelial dysfunction and tubular cell damage [77]. These processes are characterized, in the first instance, by changes in renal blood flow that may cause reduced graft perfusion and consequent renal ischemia; secondly, ischemic damage may result in a reduced cellular supply of oxygen and metabolic substrates with subsequent cellular damage, production of ROS and activation of inflammation, coagulation and complement pathways [77,78]. Lastly, these mechanisms induced significant impairment in body fluid homeostasis, with reduced GFR and consequent activation of the renin-angiotensin system, resulting in reduced urinary output with subsequent alterations in electrolytes and acid-base balance [79,80].…”

Intensive care 2.0

“…Boyer et al. discuss how to care for patients with renal failure including the technological advances in dialysis machinery [13].…”

“…Van Eldere and Pirani update us on caring for patients with liver failure [11] and Wiles et al outline the latest literature on traumatic brain injury [12]. Boyer et al discuss how to care for patients with renal failure including the technological advances in dialysis machinery [13].…”